Provider Demographics
NPI:1114969433
Name:MOHIUDDIN, ISHTIAQUE HOSSAIN
Entity Type:Individual
Prefix:DR
First Name:ISHTIAQUE
Middle Name:HOSSAIN
Last Name:MOHIUDDIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ISHTIAQUE
Other - Middle Name:H
Other - Last Name:MOHIUDDIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:PO BOX 741729
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5405 S 500 E STE 204
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7420
Practice Address - Country:US
Practice Address - Phone:801-479-0184
Practice Address - Fax:801-479-5642
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP312207RC0000X
CAA067466207RC0000X
FLME108828208M00000X
NC200400922207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137WJMedicaid
NC2031206Medicare ID - Type Unspecified
NC89137WJMedicaid